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Dermatologic surgery : an update on secondary intention healing and adjuncts : part 2Secondary intention healing (SIH) is utilised by various surgical specialities. The formation of granulation tissue is crucial for initiating the healing process, necessitating robust support at this stage. Numerous adjunct therapies are available, with new developments aimed at treating both acute and chronic wounds undergoing SIH. This article continues from part 1, examining the efficacy of various adjunct therapies in promoting SIH. This article continues from part 1, examining the efficacy of various adjunct therapies in promoting SIH.
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Left atrial appendage closure with catheter ablation vs. ablation alone on outcomes of atrial fibrillation in heart failure with reduced ejection fraction : a propensity score-matched analysisBackground Combining left atrial appendage closure with catheter ablation (LAACCA) has been proposed as a potential approach to improving outcomes by simultaneously addressing arrhythmia and reducing stroke risk. This study compares the in-hospital outcomes of LAACCA vs. catheter ablation (CA) alone for atrial fibrillation (AFib) in patients with heart failure with reduced ejection fraction (HFrEF). Methods We analyzed adult hospitalizations with HFrEF and AFib who underwent LAACCA or CA alone from the 2016-2020 nationwide inpatient sample using validated ICD-10 codes. Propensity score matching, accounting for patient-, hospital-, and procedure-level covariates, illness severity, and baseline risk of mortality, was used to alleviate bias in nonrandomized treatment assignments. The primary endpoints included all-cause in-hospital mortality, hospital stay, and hospitalization costs. Secondary endpoints included postprocedural complication rates. Prolonged hospitalization was defined as hospital stay in the top decile of hospital stay in each cohort. All statistical analyses in the study were based on weighted hospital data. Results About 233,865 HFrEF patients were hospitalized for AFib. Approximately 27,945 (11.9%) underwent LAACCA, while 205,920 (88.1%) underwent CA only. The cohort comprised mostly males (151,077; 64.6%) (mean age: 67.4; SD: 4.3). The propensity score-matched cohort comprised 18,195 LAACCAs and 18,195 CAs; all covariate imbalances were alleviated. LAACCA was associated with a higher rate of prolonged hospital stay (7.6 vs 5.6 days; P<0.001), a higher mortality rate (209 (1.1%) vs. 160 (0.9%); P=0.011), and higher mean hospital costs ($289,960 vs. $183,932; P<0.001) compared with CA alone. LAACCA was associated with a higher incidence of acute myocardial ischemia (528 (2.9%) vs. 455 (2.5%); P=0.013), complete atrioventricular block (1,200 (6.6%) vs. 892 (4.9%); P=0.004), need for implantable device therapy (1,510 (8.3%) vs. 1,348 (7.4%); P=0.017), pneumothorax (328 (1.8%) vs. 91 (0.5%); P<0.0001), hemothorax (200 (1.1%) vs. 127 (0.7%); P<0.0001), pneumonia (983 (5.4%) vs. 546 (3.0%); P<0.0001), vascular access complications (346 (1.9%) vs. 255 (1.4%); P=0.046), and septicemia (309 (1.7%) vs. 182 (1.0%); P<0.001). CA was associated with a greater incidence of cardiac tamponade (237 (1.3%) vs. 382 (2.1%); P=0.010) and femoral artery pseudoaneurysm (364 (0.2%) vs. 91 (0.5%); P<0.001). Conclusion LAACCA was correlated with higher mortality odds compared to CA alone for atrial fibrillation in HFrEF.
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A review of consent policies in Dermatological Surgery in the United Kingdom and the impact of leaner pathways and teledermatology on consentObtaining valid consent is an ethical and legal requirement in clinical practice, ensuring patients are adequately informed about their treatments. Recent updates in consent policies, including GMC guidance, the Patterson inquiry report, and key legal rulings like Montgomery, emphasise a shift towards patient-centred care and the importance of a comprehensive patient-clinician dialogue. Budget constraints and increasing NHS demand have led to the adoption of digital solutions and streamlined pathways, such as teledermatology and direct booking to surgery, potentially compromising the consent process. This review examines the current state of informed consent in UK dermatology, particularly in light of the Montgomery ruling, which requires clinicians to ensure patients are aware of all material risks and alternatives associated with their treatments. The two-stage consent process, involving consent at two distinct points, is advocated to allow patients adequate time for reflection and decision-making. However, challenges remain in pathways like one-stop clinics and direct booking for surgery, where limited face-to-face interaction and time constraints can undermine the quality of informed consent. To mitigate these issues, integrating multimedia tools and standardised procedure-specific consent forms can enhance patient comprehension and satisfaction. These tools ensure consistent and clear communication of risks, benefits, and alternatives, maintaining robust informed consent amidst evolving healthcare delivery models. Sustaining a thorough and individualised dialogue throughout the patient care journey is essential for upholding patient autonomy and shared decision-making in dermatological surgery.
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A case report of Peritoneal Mesothelioma as an Acute Abdomen Mimic : a rare presentation and diagnostic challengesMalignant peritoneal mesothelioma (MPM) is a rare and aggressive cancer often linked to asbestos exposure. This case report presents a 60-year-old man with a history of asbestos exposure who developed MPM, initially presenting with acute abdominal pain, an uncommon mimic of the acute abdomen. Diagnosing MPM is challenging due to its vague symptoms, often leading to delayed diagnosis. Additionally, the patient developed internal jugular vein thrombosis, a rare complication associated with malignancies. This case highlights the rare presentation of peritoneal mesothelioma as an acute abdomen mimic, the diagnostic complexities associated with MPM, and the rare type of thromboembolic event in this case.
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National Dermatological Surgery Sustainability Survey : an evaluation of healthcare professional beliefs and practicesBackground: Dermatological surgery contributes to the large environmental impact of healthcare, but to date there are no data on the current sustainability practices, attitudes, or behaviours of UK and Republic of Ireland health professionals involved in skin surgery. Objectives: We sought to evaluate this using a national sustainability questionnaire, organised by the British Society for Dermatological Surgery. Methods: Over 12-weeks, a 17-item online questionnaire was distributed nationally to healthcare professionals involved in skin surgery. Results: 115 UK healthcare professionals responded. 'See and Treat' provision for non-Mohs skin surgery was described by 32% of respondents. When compared to single-use equipment (Median=4), reusable equipment (Median=7) outperformed on perceived safety (p =.0056), quality (p =.00001), and patient outcomes (p =.0067), but no difference was found in usability (p =.68916). Perceived sustainability was greater in the reusable (Median=7) than single-use (Median=1)(p=.00001). Almost all (97%) respondents believe global climate change is happening, and the majority (74%) are concerned by dermatological surgery's impact. However, only 44% feel comfortable discussing health effects of climate change with patients. Whilst 75% turn off surgical lighting in between lists, often room lighting (31%), equipment (32%) or heating/air conditioning (22%) is forgotten. Conclusion: Whilst awareness of the impact of dermatological surgery on global climate change is common among healthcare professionals involved in skin surgery, there is room for improvement in translating this into local action, advocacy, and service improvement to standards dictated by national sustainability guidance.
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Disseminated tuberculosis in a patient on tumor necrosis factor (TNF)-α inhibitor treatment for ankylosing spondylitis : a case reportTumour necrosis factor-alpha (TNF-α) inhibitors are commonly used in the treatment of ankylosing spondylitis (AS) due to their effectiveness in reducing inflammation and slowing disease progression. However, their use is associated with an increased risk of opportunistic infections, particularly tuberculosis (TB). This case report presents a young male patient in the United Kingdom (UK) with AS, who had been on long-term biological therapy with adalimumab, a TNF-α inhibitor. The patient developed disseminated TB, which rapidly progressed and unfortunately resulted in the patient's death. This case underscores the importance of comprehensive screening for latent TB before initiating TNF-α inhibitor therapy, as well as ongoing monitoring throughout treatment. Given the multicultural nature of the UK, where individuals may be exposed to TB without traveling to endemic areas, careful attention to TB risk across all ethnicities is critical. This case highlights the need for heightened vigilance and tailored preventive strategies to mitigate the risks of TNF-α therapy.
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Environmental sustainability in dermatological surgery : part 1 : reducing carbon intensityThis two-part review addresses the pressing need for environmental sustainability in dermatological surgery, driven by the NHS's commitment to net-zero emissions. Part 1 focuses on strategies to reduce the carbon intensity of dermatological procedures by adopting low-carbon alternatives and optimising operational resource usage. Key strategies for a system-wide reduction in environmental impact include using leveraging local suppliers to reduce transport emissions, streamlining care models, promoting efficient waste management, and using mindful prescribing practices. Another aspect is integrating sustainability into dermatological education whilst minimising the carbon footprint of surgical education. Additionally, the review provides a comprehensive overview of optimising resource use in dermatological surgery, focusing on efficient management of consumables, equipment, and energy. This includes recycling, waste segregation, transitioning to reusable personal protective equipment and surgical instruments, and applying energy-saving and sustainable water use practices. By implementing these strategies, dermatological surgery can significantly reduce its environmental impact while upholding high standards of patient care.
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Environmental sustainability in dermatological surgery : part 2 : reducing activity and future ecological strategiesThis two-part review addresses the pressing need for environmental sustainability in dermatological surgery, driven by the NHS's commitment to net-zero emissions. Part 2 of this review extends the discussion of sustainability in dermatological surgery by focusing on system-wide changes in service delivery and identifying future opportunities for reducing environmental impact. Building on the strategies outlined in Part 1, which explored low-carbon alternatives and operational resource optimisation, Part 2 advocates for a comprehensive shift in the skin surgery service. Key strategies include reducing overall surgical activity, advancing research and innovation, and enhancing management practices to align with sustainability goals. Reducing surgical activity mainly involves the prevention of skin cancers, in addition to optimising current patient pathways and empowering patients to take ownership of their follow-up. Outside of immediate clinical decision-making at the individual level, the review highlights the importance of managerial policy, procurement practices and supply chain factors in driving broader national and international sustainability efforts. Advancing the sustainability agenda will also require targeted research and innovation, particularly in digital health solutions using evidence-based practices. By integrating these strategies, this review aims to provide a framework for reducing the environmental footprint of dermatological surgery and advancing towards a more sustainable healthcare system.
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The natural progression of basal cell carcinomas in patients awaiting surgical interventionBasal cell carcinomas (BCCs) are slow growing keratinocyte tumours with limited literature reporting the natural history of untreated BCCs. This study evaluated the natural progression and patient outcomes of BCCs whilst awaiting surgical intervention. Only patients with histologically proven BCCs were included in the data collection. Retrospective data analysis was performed on 55 patients (total of 70 lesions) and showed a statistically significant correlation between average growth of BCCs and time waiting for a procedure. Twenty percent of the cases had a larger procedure than originally planned at the time of booking. The top three symptoms reported include itching (39.4%), crusting (36.4%) and bleeding (30.3%). In conclusion, we reported a positive relationship between BCC growth and length of time from initial presentation to surgical treatment where patients often ended up with more symptoms, larger and complex surgical procedure than originally planned especially on the head and neck.
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53300 Ascertaining current beliefs surrounding sunscreen : a national survey in the UKNo abstract available
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Podocyte infolding glomerulopathy masquerading as membranous nephropathy - a shared pathogenesis?Podocyte infolding glomerulopathy (PIG) is a rare pathological entity, diagnosed by electron microscopic demonstration of diffuse infolding of the podocytes into the glomerular basement membranes. We report the first case from United Kingdom exhibiting typical ultrastructural features of PIG in a male with Type II diabetes mellitus, hypertension and common variable immune deficiency. Renal biopsy revealed phospholipase A2 receptor (PLA2R) immunostain positive membranous nephropathy (MN) but no serum PLA2R antibodies. Diffuse infolding of the podocytes into the glomerular basement membranes along with pathognomonic microspherular and microtubular intra basement membrane clusters distributed diffusely and globally were noted on electron microscopy, diagnostic of PIG. We postulate a shared pathomechanistic link between PIG and MN, highlighting the overlapping features of both conditions.
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Appraisal of AI-generated dermatology literature reviewsBackground: Artificial intelligence (AI) tools have the potential to revolutionize many facets of medicine and medical sciences research. Numerous AI tools have been developed and are in continuous states of iterative improvement in their functionality. Objectives: This study aimed to assess the performance of three AI tools: The Literature, Microsoft's Copilot and Google's Gemini in performing literature reviews on a range of dermatology topics. Methods: Each tool was asked to write a literature review on five topics. The topics chosen have recently had peer-reviewed systematic reviews published. The outputs of each took were graded on their evidence and analysis, conclusions and references on a 5-point Likert scale by three dermatologists who are working in clinical practice, have completed the UK dermatology postgraduate training examination and are partaking in continued professional development. Results: Across all five topics chosen, the literature reviews written by Gemini scored the highest. The mean score for Gemini for each review was 10.53, significantly higher than the mean scores achieved by The Literature (7.73) and Copilot (7.4) (p < 0.001). Conclusions: This paper shows that AI-generated literature reviews can provide real-time summaries of medical literature across a range of dermatology topics, but limitations to their comprehensiveness and accuracy are apparent.
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Gaining exposure on perceptions of sunscreen : a national survey of melanoma patientsThe incidence of melanoma is increasing. We ascertained perceptions regarding sunscreen and factors influencing choice in patients with melanoma. A survey was distributed to all members of a support group for people with melanoma. In total, 571 responses were received across 6 weeks. Most respondents (n = 452/571; 79.2%) indicated that they knew how much sunscreen to apply; the most popular frequency of application was once daily (n = 180/571; 31.5%). The most popular cosmetic benefit respondents indicated was reduced redness on sun-exposed areas of the skin (n = 418/571; 73.2%). Most respondents (n = 552/571; 96.7%) agreed that more education is needed regarding the importance of wearing sunscreen. The three most popular factors influencing sunscreen choice were a sun protection factor (SPF) > 50 (n = 299/571; 52.4%), dermatologist recommendation (n = 267/571; 46.8%) and price (n = 262/571; 45.9). Sustainable packaging (n = 45/571; 7.9%) and ethical sourcing of ingredients (n = 65/571; 11.4%) were not ranked highly. Given that 42.0% (n = 240/571) only applied sunscreen on sunny days, an education campaign is required. Industry should consider public education regarding sustainability. A further study ascertaining the views and perceptions of sunscreen in a cohort of people without melanoma is strongly encouraged.
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Estimating the burden of vitiligo : a systematic review and modelling studyBackground: Vitiligo is a chronic autoimmune disease characterised by depigmented skin patches, which can pose substantial psychosocial challenges particularly in individuals with dark skin tones. Despite its impact on quality of life, there is an absence of standardised global epidemiological data. We sought to address this gap with the present study. Methods: In this study we did a systematic review and modelling analysis to estimate the global, regional, and national prevalence and incidence of vitiligo. We did a comprehensive search of nine digital libraries (PubMed, Embase, Web of Science, Scientific Electronic Library Online, KCI Korean Journal Database, Russian Science Citation Index, Western Pacific Region Index Medicus, Informit, and Health Research and Development Information Network) from inception up to May 25, 2023. We included cross-sectional or cohort studies reporting the incidence rate or prevalence of vitiligo, or data from which incidence rate or prevalence could be calculated, in the general population of a country or area of a country. Summary estimate data were extracted. A main outcome was to estimate the worldwide, regional, and country-specific lifetime prevalence of vitiligo diagnosed by physicians or dermatologists among the general population and in adults and children (as per age groups defined in included studies). We used a Bayesian hierarchical linear mixed model to estimate prevalence, and calculated number of affected individuals using the UN population structure in 2022. In estimating lifetime prevalence, studies reporting point or period prevalence were excluded. Our other main outcome was to estimate incidence rates of vitiligo, but due to a small number of studies, the data on incidence were presented in a descriptive summary. This study was registered on PROSPERO, CRD42023390433. Findings: Our search identified 22 192 records, of which 90 studies met our inclusion criteria. Of these studies, six focused on the incidence of vitiligo, 79 reported on the prevalence of vitiligo, and five provided data on both incidence and prevalence. 71 studies reported on lifetime prevalence. In the most recent years studied, incidence rates in the general population ranged from 24·7 cases (95% CI 24·3-25·2) per 100 000 person-years in South Korea in 2019, to 61·0 cases (60·6-61·4) in the USA in 2017. In individual studies, incidence rates showed an increasing trend over the periods studied. The global lifetime prevalence of vitiligo diagnosed by a physician or dermatologist was estimated at 0·36% (95% credible interval [CrI] 0·24-0·54) in the general population (28·5 million people [95% CrI 18·9-42·6]), 0·67% (0·43-1·07) in the adult population (37·1 million adults [23·9-58·9]), and 0·24% (0·16-0·37) in the child population (5·8 million children [3·8-8·9]). Vitiligo prevalence was higher in adults than in children across all regions. Central Europe and south Asia reported the highest prevalence (0·52% [0·28-1·07] and 0·52% [0·33-0·82], respectively, in the general population). Interpretation: This study highlights the need for standardised epidemiological data collection globally to inform public health policies and improve vitiligo diagnosis and management. Emphasis on the impact on individuals with darker skin tones is crucial to reducing stigma and improving quality of life. Furthermore, our study highlights the need to conduct more research in regions and populations that have been historically under-represented, to effectively address the worldwide burden of vitiligo.
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Technology-enhanced learning interventions on skin of colour dermatology for dermatology trainees and fellows : are they effective or sustainable?Recent shifts towards synchronous online learning and raised awareness of ethnic inequalities in health have resulted in the establishment of frequent 'one-off' technology-enhanced learning (TEL) initiatives on diversity issues. There is little established evidence regarding the efficacy or sustainability of such interventions. We designed a prospective cohort pilot study including 14 dermatology registrars and fellows and delivered a TEL programme focusing on central centrifugal cicatricial alopecia and keloid scarring. Information was collected on the existing competence and confidence of our cohort about managing these conditions, as well as the short-term and long-term impact of our intervention. Following our programme, participant knowledge improved transiently, but was not sustainable 6 weeks later. Over half of participants were not confident in adopting newly acquired knowledge on skin of colour into practice. Results demonstrate a disparity between how effective one-off education initiatives are perceived vs. actual benefit. More systemic solutions may be warranted.
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Exploring BAME student experiences in healthcare courses in the United Kingdom : a systematic reviewIntroduction: Black, Asian, and Minority Ethnic (BAME) students in healthcare-related courses are exposed to various challenging experiences compared to their White counterparts, not only in the UK (United Kingdom) but across the globe. Underachieving, stereotyping, racial bias, and cultural differences, among other experiences, hinder their medical education, practice, and attainment. This review aimed to explore and understand the experiences of BAME students enrolled in healthcare related courses in the United Kingdom. Methods: Computerised bibliographic search was carried out using MeSH and free text descriptors via PubMed, Cochrane, Google Scholar, and Science Direct for eligible English-published studies exploring BAME experiences in the UK from 2010-2023. Results: A cumulative total of 813 studies were obtained from the literature search, of which five met the inclusion criteria. Quality assessment for risk of bias was assessed using the Newcastle Ottawa scale, yielding one study of satisfactory quality, while four were deemed to be of good quality. Conclusion: BAME students pursuing health-related courses across the UK. face a range of experiences, including racial discrimination, unconscious bias, and a lack of representation and support. Additionally, BAME students are more likely to report incidents of racial harassment and withdraw from their respective courses as well as experiencing mental health issues due to their experiences.
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A progressive and severe rash - answersA 73-year-old female patient with epilepsy presented to hospital with a progressive, diffuse macular rash over the trunk and limbs with associated mucosal blistering and discharge. Ocular symptoms initially predominated and she was treated for presumed bacterial conjunctivitis by her General Practitioner the previous day. On the acute medical unit supportive management was initiated for suspected adverse drug reaction (ADR) to a recent lamotrigine dose increase. Skin biopsy confirmed a diagnosis of toxic epidermal necrolysis. We present this case to highlight the importance of medication history taking and raise awareness of indolent presentations of life-threatening ADRs. Caution should be applied following dose changes to anti-epileptics, even if previously stable.
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A progressive and severe rashA 73-year-old female attended the Emergency Department with a twenty four hour history of a progressive, diffuse macular rash, predominantly affecting limbs and trunk, with associated oral and ocular discharge.